=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598404535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANYELL JANEE JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2022
-----------------------------------------------------
Last Update Date | 05/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3807 DICKERSON PIKE STE J
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37207-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-578-3693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 469 PONDER PL APT 202
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37228-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------